The Clements’ IVF Journey

Welcome back, Insurance Games. Now DIE!! January 6, 2009

Insurance games continue. And we have proof. They’re trying to not pay for the meds. As of November, we had spent about $2,000 of our $5,000 cap. We have proof. Their own bills. (Our co-pay was $140, but insurance companies have to send full bills so you can see what’s been charged.) This time around we only need a couple of them, and they aren’t covering. Why? We didn’t know. The pharmacy told us, and didn’t know why. So I called United, our insurance company.

I dialed the number on the back of our insurance card, 866-348-1286. The first United rep I spoke with (whose name I forgot to ask) verified our copay should only be $35 for the Menopur. She didn’t see any reason it should be more. So she transferred me to Diane, who said the same thing. So she transferred me to Shamika, who was beyond pointless. Rather than ask anything, she told me she knew nothing and would transfer me to MedCo, United’s prescription division. She transferred me to Dana. Dana also said it should be $35. Then she said wait, the Follistim was charged at $4,000 (in November, each of the 11 vials were $75 each, $825 total). So never mind, nothing is covered at all anymore. When I asked her how the price had changed, she said she didn’t know, call the number on the back of my insurance card (which is the number I called and ended up being transferred to her.

So I called the same number again, this time speaking with Dario. Dario couldn’t find anything either, so called Janice with MedCo. This was a conference call. Janice was saying that I need to tell her how things we billed because she didn’t have access to billing codes. Um, like I would? Billing codes is insurance stuff. She’s the insurance person. Yet I was supposed to know? She said she didn’t have access to what was billed, when, names of meds, etc., and Dario admitted being confused about how I could be denied prescription coverage by the prescription division if no one can tell me what’s been billed. How can they decide to not cover without telling me anything? Finally she said that the total spent under the caps was $4,600, and began giving numbers, $4,000 for the Follistim, $900 for the Menopur – already it doesn’t add up right (and remember earlier in the call she said she didn’t have access to this information). Dario mentioned this. Janice immediately transferred us to someone else, Darlene. Darlene said they had access to nothing, no break-down, but she did see that we were at $5,781 of that $5,000-cap. Dario heard the two different figures from two different people, and asked also how the costs were different when nothing changed. Darlene said maybe Janice looked at something wrong.

United has said we can file a written appeal for reconsideration and they MIGHT reimburse us then, but that takes six months. Monday is six DAYS away.

Hmmmm, so a rep “looking at something wrong” means clients are given wrong information. We clients rely on the reps to give us the correct information. And here’s one saying someone else gave me the wrong information. How am I supposed to have faith in an insurance company that keeps giving contradictory and incorrect information?

So now we’ve supposedly spent either $4,600 or $5,781 of that $5,000-cap (even though they supposedly don’t have access to what’s been spent, how it’s been spent, or how it’s been billed, but I’m supposed to know billing codes). Yet the bill we received shows about $2,000. We’ve moved since November, so I need to dig this out. I have no doubt at all in my mind what it was. The Follistim was $75.

I did a long Google-search and found 3 of the 300IU cartridges of Follistim average about $200 for insurance to pay. (Insurance companies tend to get discounted rated while self-pay is usually more, and this goes also fo self-paying when seeing a doctor!).

After beginning this entry, after I finished that last paragraph, I decided to call the pharmacy we use. They told me they charge self-pay clients $228 per cartridge. So even if we were self-paying, the Follistim wouldn’t have cost us more than $2,508. And insurance companies get a rate at about a third of the self-pay rate for this drug, which would be a little over $800, which is about on par with what the original bill we got. In other words, no where NEAR the $4,000 United/MedCo are now claiming to have paid.

What this means for us us now though is that, two weeks into the cycle, we are now $350 short. We need these meds by Monday. They’re mail-order from the East Coast, so we have two days to come up with $350, or else we have to stop. We can pay what the pharmacy is charging, which is based on what United will/won’t cover, or wait several more months. We need another $350. If we can come up with it, you bet we’ll go forward now and file the appeal with United with the copy of the bills we’ve received to date and a statement from the pharmacy of what they actually charge, and if United won’t reimburse, well, we can either get an attorney on a contingency, or ask my aunt to take the case (and demand punitive for their lies and the heartbreak their lying has caused). She’s dealt with fertility issues and never succeeded in having a baby. Sadly, she knows how this feels.

We’d rather United just knock it the fuck off and pay (though nothing will get them out of a formal complaint with the state insurance commissioner) rather than for us to have to sue. If someone from United sees this and can get United to just pay, that’s fine with us. It’ll take less time, and save United some attorney fees and having to explain, on public record, why they’ve lied so many times.

We’re being sent a bill from United showing the prescription “charges” for November. However we already have a bill for November. Meaning they’re sending us proof of changing costs to get out of paying for things. Either that, or they’ll send us a bill showing the same costs of the bill we already have, which would mean they are supposed to cover the meds this time. Either way, whatever they send will fuck them one way or another.

We’ve kept every single piece of paper that’s come our way, even print-outs regarding support groups, things not directly related to us specifically. I’ve kept track of every person (except a couple times I forgot to get names) we’ve spoken to, and what the conversation was about. Today the big kicker now is that the pharmacy has told me they don’t charge anywhere near what United is claiming to have been billed.

United has lied again. Trying to get out of paying. We’re gathering more proof.